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Individual & Couples Therapy Intake Form
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Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Address
Your answer
What is the name of person who will be attending therapy with you (if applicable)?
Your answer
What is their relationship to you?
Your answer
Phone Number
*
Your answer
How would you prefer to be contacted?
*
Phone
Email
Other:
What is your ethnicity?
Your answer
What gender do you identify as?
Female
Male
Prefer not to say
Other:
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Which pronouns do you prefer to use?
Your answer
Date of birth
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/
DD
/
YYYY
Are you currently employed?
Yes
No
Other:
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If yes, where?
Your answer
Do you have a valid Driver’s License or other State Identification?
Yes
No
Clear selection
If so, please provide license number and state.
Your answer
What type of medical insurance do you have?
Your answer
Why are you seeking therapy?
Your answer
Have you ever been in therapy before?
Yes
No
Other:
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Would you described the experience as helpful or unhelpful?
Helpful
Unhelpful
Other:
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Send me a copy of my responses.
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